retention of health records in hospital setting policy

1. NABH-Retention
Issue No. 1 Issue Date: 03/ 20 Page 1 of 4
POLICY
ON
RETENTION OF RECORDS

2. NABH-Retention of Records
Issue No. 1 Issue Date: 03/ 20 Page 2 of 4
Objective
This policy is to ensure that the necessary records and documents are adequately protected
and maintained and to ensure that the records that are not current or are no longer needed
or are of no value are systematically discarded at the proper time. The policy shall cover all
the records mentioned in the document. The document also provide guidance for retaining
electronic documents, including emails, web files, PDF documents and all MS office and
other formatted files.
Policy
This Policy is regarding the retention and disposal of records and also the retention and
disposal of electronic documents.
Applicability
This policy applies to all physical records generated in the course of operation of NABH
including both original document and reproduction. It also applies to electronic documents as
well.
Retention of Records
NABH during the process of its operation produce records which has been categorized
below and the time duration of has been defined:
Sl Records Retention
1 Records pertaining to Accreditation
Process
a) Applications ( First and Renewal)
b) Assessment reports (pre-assessment, final
assessment, surveillance, renewal
assessment, surprise assessment, focus
assessment)
c) Copy of Accreditation Certificate and Scope
of accreditation/certification for each HCO
a) Records of applications will be
maintained in soft copies on the
portal/ scanned copies for a
period of three years from the
date of application
b) Records of accredited HCOs
shall be maintained in a manner
such that at least 3 Assessment
reports including corrective
actions & relevant
communications are maintained
in soft copy on the portal of
NABH.
c) 10 years as soft copy on server

3. NABH-Retention of Records
Issue No. 1 Issue Date: 03/ 20 Page 3 of 4
Sl Records Retention
2 Records pertaining to Inspection for
Empanelment (CGHS & ECHS) Inspection
reports and recommendation letter
Records of inspections shall be
maintained for 5 years as soft copy
on the local server of NABH.
3 Records pertaining to Committees
a) NABH Board ( formation of Board, agenda,
MOM, Declaration of Confidentiality &
Impartiality and self evaluation forms)
b) Accreditation Committee records
(committee formation, agenda, MOM,
Declaration of Confidentiality & Impartiality
and self evaluation forms)
c) Technical Committee records (committee
formation, agenda, MOM, Declaration of
Confidentiality & Impartiality and self
evaluation forms)
d) Legal documents, Complaints Committee
and Appeals records (register,
correspondence)
e) Assessor Management Committee records
(agenda, MOM)
f) Risk and Improvement Committee records
(agenda, MOM)
a) Records related to NABH Board
shall be maintained forever as
scanned copies on local server
of NABH.
b) & c) Records related to
Accreditation Committee and
Technical Committee shall be
kept for last 8 years including
decisions on emails (as scanned
copies on server)
d) Legal documents and Records
related to Complaints and
Appeals shall be kept forever as
hard copies
e) Records related to Assessor
Management Committee shall be
kept for last 8 years as scanned
copies on server of NABH.
f) Agenda and MOM of RIC shall
be maintained for 8 years as soft
copies on server of NABH
4 Records pertaining to Internal Audit
(Internal Audit Reports, Corrective action
report)
Records related to Internal Audit can
be kept for 8 years as scanned
copies on the server.
5 Records pertaining to Training
programmes
a) Assessor Training (budget approval,
attendance sheet, photographs,
certificates)
b) Programme on Implementation (budget
approval, attendance sheet, photographs,
certificates)
c) Education Workshops (budget approval,
attendance sheet, photographs,
certificates)
 Records related to Assessor
Course shall be kept forever.
However, NABH shall scan all
the papers before actual
destroying of papers which shall
be saved on local server.
 Records related to other training
programmes at S.No. b, c and d
shall be kept for last 5 years as
soft copies on local server.

4. NABH-Retention of Records
Issue No. 1 Issue Date: 03/ 20 Page 4 of 4
Sl Records Retention
d) Awareness programme (budget approval,
attendance sheet, photographs,
certificates)
6 Records pertaining to control of NABH
Documents (approval of documents, current
document, obsolete document)
Records related to NABH Document
approval shall be kept for last 5
years as hard copies as well as soft
copies on the server.
7 Records pertaining to Staff of NABH Till employment as hard copies
8 Emails The emails of the officials of NABH
shall be stored for last 5 years
Discard Policy for Records
NABH is now maintaining the soft copies of all available records as mentioned in the above
table. As per the retention timeline of that particular record, the records shall be discarded
after the concerned officer submits his/ her consent for destroying. NABH official shall
ensure that above time period of retention is adhered to.
The physical records will be weeded twice a year on the 1st
of January and 1st
of July and no
further notification shall be given for the purpose.
The records of accreditation process of HCOs in the server shall have the same retention
period as mentioned in the above table.

5. NATIONAL ACCREDITATION BOARD FOR HOSPITALS
AND HEALTHCARE PROVIDERS (NABH)
Quality Council of India
ITPI Building, 5th
Floor, 4-A,
I P Estate, Ring Road, New Delhi – 110002, India
Tel: 91-11- 42600612.
Website-www.nabh.co
E-mail : helpdesk@nabh.co